Indig et al. BMC Public Health 2013, 13:1200http://www.biomedcentral.com/1471-2458/13/1200

RESEARCH ARTICLE Open Access

Heroin use impairs smoking cessation amongAustralian prisonersDevon Indig1,2*†, Alex D Wodak3†, Robyn L Richmond2†, Tony G Butler4†, Vicki A Archer1† and Kay A Wilhelm5,6†

Abstract

Background: Prisoners have extremely high rates of smoking with rates 3–4 times higher than the generalcommunity. Many prisoners have used heroin. The aims of this study were to investigate the impact of heroin useon smoking cessation and the social determinants of health among prisoners.

Methods: Secondary analysis of data from a randomised controlled trial of a multi-component smoking cessationintervention involving 425 Australian male prisoners. Inmates who, prior to imprisonment, used heroin regularlywere compared to those who did not use heroin regularly. Self-reported smoking status was validated at baselineand each follow-up by measuring carbon monoxide levels. Readings exceeding 10 ppm were defined as indicatingcurrent smoking.

Results: Over half (56.5%) of the participants had ever used heroin while 37.7% regularly (daily or almost daily) usedheroin in the year prior to entering prison. Prisoners who regularly used heroin had significantly worse socialdeterminants of health and smoking behaviours, including lower educational attainment, more frequent incarcerationand earlier initiation into smoking. Prisoners who regularly used heroin also used and injected other drugs significantlymore frequently. At 12-month follow-up, the smoking cessation of prisoners who had regularly used heroin was alsosignificantly lower than prisoners who did not regularly use heroin, a finding confirmed by logistic regression.

Conclusions: Regular heroin use prior to imprisonment is an important risk factor for unsuccessful attempts to quitsmoking among prisoners and is also associated with worse social determinants of health, higher drug use, and worsesmoking behaviours. More effective and earlier smoking cessation interventions are required for particularlydisadvantaged groups.

Trial registration: This trial is registered with the Australian New Zealand Clinical Trials Registry 12606000229572.

Keywords: Heroin, Prisoner, Smoking cessation, Nicotine dependence

BackgroundSmoking cessation efforts among the Australian commu-nity have led to a decline in smoking prevalence from ahigh of 72% of men and 26% of women in 1945 to acurrent regular smoking rate of 22% in men and 18% inwomen [1,2]. However, this trend is not seen in sociallydisadvantaged populations, such as prisoners, those witha mental illness, and illicit drug users [3-5]. The 2009

* Correspondence: d.indig@unsw.edu.au†Equal contributors1Justice & Forensic Mental Health Network, Centre for Health Research inCriminal Justice, Suite 302, Level 2, 152 Bunnerong Road, Pagewood, NSW2035, Australia2School of Public Health and Community Medicine, University of New SouthWales, Sydney, NSW 2052, AustraliaFull list of author information is available at the end of the article

© 2013 Indig et al.; licensee BioMed Central LCommons Attribution License (http://creativecreproduction in any medium, provided the or

New South Wales (NSW) Inmate Health Survey, whichrandomly sampled 996 prisoners in custody, reported75% of male and 80% of female prisoners were currentsmokers [6]. Among those entering prisons acrossAustralia, the rate of smoking was higher (85%), and high-est among prisoners reporting a history of injecting druguse (93%) [7]. However, a substantial proportion of pris-oners report wanting to stop smoking [3,6,8,9].The 2012 World Drug Report estimates that between

0.6% and 0.8% of the world’s population aged between15 and 64 years used opioid drugs with heroin the mostwidely used opioid [10]. In Australia in 2010, amongthose aged 14 and over 1.4% reported using heroin while0.2% used heroin in the previous year [1]. The rate ofheroin use was significantly higher among prisoners in

td. This is an open access article distributed under the terms of the Creativeommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andiginal work is properly cited.

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NSW with 41% reporting having ever used heroin, 10%using heroin on a daily/almost daily basis in the pastyear and 15% having ever used heroin in prison [6].Among Australian prison entrants who participated in aNational Prisoner Health Census in 2009, 19% of pris-oners reported using heroin in the year before enteringprison [11]. Heroin use among prisoners and thebroader Australian community has decreased in the pastdecade following the heroin shortage of 2000, but ratesare still high [12,13].Most people who currently use heroin or are on

opioid substitution treatment (such as methadone orbuprenorphine) also smoke cigarettes [9]. A recentAustralian study found the prevalence of smoking was84% among methadone users [14] and another study ofheroin users reported 97% were smokers [15]. A qualita-tive study [16] asked drug users currently in treatmentabout the relationship between their smoking, methadoneand drug use. The participants reported that drug use andsmoking were complementary in managing side effects ofboth substances and withdrawal symptoms [16]. Smokingcessation rates among opioid-dependent people are lowerthan among the general population, however many stillwant to quit [17,18].Few studies have investigated how heroin use may

affect smoking cessation intervention outcomes [19].The aims of this paper were to assess the impact ofregular heroin use in the year before entering prison onthe social determinants of health, smoking behaviours(such as age of initiation and amount smoked per day)and success of quitting smoking among prisoners. As ahigh proportion of prisoners are current smokers andhave used heroin, it is important that we improve ourunderstanding of the relationship between the two inorder to develop more effective smoking cessation inter-ventions for this high risk and socially disadvantagedpopulation.

MethodsStudy designThis study involved a secondary analysis of data from arandomised controlled trial of a multi-component smok-ing cessation intervention among prisoners. This analysiscompared prisoners who, prior to imprisonment, wereregular (daily or almost daily use) heroin users with pris-oners who were not regular heroin users (i.e. used her-oin less than regularly). The trial recruited 425 maleprisoners who received 13 weeks of nicotine replace-ment therapy, two sessions of brief cognitive behaviouraltherapy, had access to a Quitline, and were providedwith smoking cessation support materials (e.g. a bookletdesigned by the investigators to assist with coping withprison stressors and a QUIT calendar). Participants wererandomised to receive either active nortriptyline or placebo

to assess the impact of the antidepressant on assistingparticipants to quit smoking. Ethics committees from theUniversity of New South Wales, Justice Health NSW,Corrective Services NSW, the Aboriginal Health andMedical Research Council and Queensland CorrectiveServices approved the study. A full description of themethods, study intervention and results of the randomisedcontrolled trial are reported elsewhere [20].

Participants and recruitmentRecruitment took place in 17 prisons in NSW (N = 407)and one prison in Queensland (N = 18) among prisonerswho were current smokers and who indicated theywished to quit smoking. Between August 2006 andSeptember 2009, 1,751 prisoners expressed interest inparticipating in the study and were assessed by a re-search nurse and doctor regarding the selection criteria.The majority (N = 1,315) were considered ineligible forthe following reasons: having less than six months lefton their sentence (35%), being on psychiatric medicationor having a history of psychiatric illness (40%) or a his-tory of cardiac disease (5%). Female prisoners were con-sidered ineligible, as they only constitute 7% of the NSWprisoner population and generally have shorter sentences[21]. All participants provided written informed consentand were paid $10 for each interview completed. Partici-pants were followed up both in prison and the communityat 3, 6 and 12 months to assess the point prevalence, con-tinuous abstinence and smoking reduction. Follow-uprates were 90% at 3 months, 87% at 6 months, and 80% at12 months, with no difference in follow-up rates for par-ticipants in the active nortriptyline and placebo groups.There was also no significant difference among partici-pants who were regular or not regular heroin users regard-ing their assignment to treatment or placebo group, orwith regard to their rate of follow-up.

Questionnaires and measuresParticipants were administered a baseline questionnaireface-to-face by research nurses. The baseline ques-tionnaire included questions on socio-demographics,offending history, smoking behaviours, smoking history,physical health, mental health and alcohol and other druguse. The follow-up questionnaires included most of thesame measures in the baseline. The questions related touse of heroin (and all drugs) including if they ‘ever used’ or‘used regularly (daily/almost daily) in the 12 months beforeprison’. Smoking behaviours were measured using ques-tions related to the number of cigarettes smoked beforeprison, years of regular smoking and prior quit attempts.Nicotine dependence was assessed using the FagerströmTest for Nicotine Dependence [22].The primary smoking cessation outcome measures

were point prevalence, continuous abstinence and 50%

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reduction in number of cigarettes smoked (relative tobaseline) measured at 12 months. These outcome mea-sures were determined on an intention-to-treat basis [23]:if a participant missed a particular follow-up they wereregarded as a smoker at that time period. Self-reportedsmoking status was validated at baseline and each follow-up by measuring carbon monoxide levels and readingsexceeding 10 ppm were classified as a smoker [24].

Statistical analysisQuestionnaires were double-key entered into an elec-tronic database and the data were cleaned for potentialerrors. Statistical analysis was performed using SASversion 9.2 [25]. Descriptive and inferential statistics(including chi-square and t-tests) were used to determineany statistically significant differences (p ≤ 0.05) across arange of characteristics for inmates who regularly usedheroin compared with those who had not regularly usedheroin in the year before prison. For the smoking cessa-tion outcome variables, intention-to-treat analyses [23]were utilised with missing data classified as either continu-ing smoking or not reducing the amount smoked by 50%.This included chi-square analysis and logistic regressionfor the major outcome variables of point prevalence andcontinuous abstinence at 12 months. There were no sig-nificant differences in the follow-up rates for regular ver-sus non-regular heroin users. In the logistic regressionmodels, potential confounders were controlled for includ-ing any socio-demographics and other drug use character-istics which were significant.

ResultsSocio-demographics, drug use and offending history byregular heroin usersAmong the 425 male participants, over half (56.5%) hadever used heroin and 37.7% regularly (daily/almost daily)used heroin in the 12 months before entering prison.Prisoners who had regularly used heroin before prisonwere significantly younger than those who had not usedheroin regularly (Table 1). Other socio-demographic char-acteristics which were significantly worse for prisonerswho were regular heroin users included: institutionalisationas a child, leaving school with no qualification and at ayounger age and being homeless prior to entering prison.Prisoners with a history of regular heroin use in the

year before entering prison were significantly more likelyto have ever used all other types of drugs, as well asregularly (daily or almost daily) using all other types ofdrugs prior to prison than prisoners who were not regu-lar heroin users prior to entering prison. Similarly, pris-oners who were regular heroin users prior to enteringprison were significantly more likely to have been previ-ously incarcerated and had twice as many adult prisonterms than prisoners who were not regular heroin users.

Smoking history, cessation behaviours and outcomes byregular heroin usersThe mean ages for first smoking tobacco and for smok-ing tobacco on a daily basis were significantly lower forprisoners who were regular heroin users compared tothose who were not regular heroin users (Table 2). Therewere no significant differences between participants whoregularly used heroin and those who did not with regardto the quantity of tobacco smoked or nicotine depend-ence score. Participants who had regularly used heroinwere significantly less likely to have attempted unsuccess-fully to quit smoking in the past year, but there were nosignificant differences in the number of quit attempts.The outcomes of the smoking cessation intervention

identified lower rates of quitting smoking for pointprevalence (5.0% vs. 18.5%, P < 0.01) and continuous ab-stinence (3.8% vs.16.6%, P < 0.01) at 12-month follow-upfor participants who were regular heroin users prior toprison. There were no significant differences betweenparticipants who were regular heroin users and thosewho were not with regard to having taken the studymedication (NOR), nor with the outcome of reducingthe quantity of tobacco smoked by 50% at 12 months.

Predictors of smoking abstinenceTable 3 identifies potential predictors of smoking abstin-ence (both point prevalence and continuous abstinence)at 12 months, including socio-demographic, drug useand smoking behaviours which were significantly differ-ent between participants who, before entering prison,were regular heroin users and those who were not. Thecrude odds ratio for both models identified the followingpredictors of successfully quitting smoking at 12 months:being in prison for the first time, being in prison for fiveor more years, not being a regular heroin user and notbeing a regular user of other drugs (excluding heroin).When these predictors which were significant in thecrude model were incorporated into the logistic regres-sion model, not being a regular heroin user was the pri-mary predictor for both point prevalence (OR = 3.81,95% CI: 1.65-8.78) and continuous abstinence (OR = 4.29,95% CI: 1.69-10.90).

DiscussionThis paper concludes that heroin use in the year beforeentering prison is associated with a reduced likelihoodof stopping smoking at 12 months following a multi-component smoking cessation intervention. This findingremained significant after controlling for regular use ofdrugs other than heroin, which strengthens the specifi-city of this association. Though there are a number ofstudies identifying the importance of implementingsmoking cessation interventions among people in opioidtreatment programs [5,26,27], no studies were found which

Table 1 Socio-demographics, drug use and offending history by regular use of heroin in year before prison

Not regularly used heroin %(N = 265)

Regularly used heroin %(N = 160)

Total men %(N = 425)

P-value

Socio-demographics

Age group

< 25 years 25.3 19.4 23.1

25-29 years 17.4 24.4 20.0 P < 0.01

30-39 years 23.4 37.5 28.7

40+ years 34.0 18.9 28.2

Mean age 34.4 32.0 33.5 P < 0.02

(+SD; Range) (11.2; 18–65) (8.0; 19–54) (10.2; 18–65)

Aboriginal origin 14.3 16.3 15.1 NS

Born in Australia 74.8 75.0 74.9 NS

Left school no qualification 39.3 50.6 43.5 P < 0.03

Mean age left school 15.5 14.6 15.1 P < 0.01

(+SD; Range) (1.7; 12–26) (2.3; 0–19) (2.0; 0–26)

Institutionalised as a child (juvenile detentionand/or placed in care)

31.3 48.8 37.9 P < 0.01

Homeless prior to prison 4.5 11.3 7.1 P < 0.01

Employed while in prison 79.3 60.0 72.0 P < 0.01

Ever use drugs by drug type

Cannabis 89.1 98.8 92.7 P < 0.01

Amphetamines 66.0 95.0 76.9 P < 0.01

Cocaine 44.2 81.9 58.4 P < 0.01

Heroin 30.1 100.0 56.5 P < 0.01

Other opiates 18.9 66.9 36.9 P < 0.01

Tranquilisers 22.6 66.9 39.3 P < 0.01

Any drugs (other than heroin) 92.1 100.0 38.6 P < 0.01

Any drugs 92.5 100.0 95.3 P < 0.01

Regularly (daily or almost daily) use drugsprior to prison by drug type

Cannabis 52.8 73.1 60.5 P < 0.01

Amphetamines 41.9 60.0 48.7 P < 0.01

Cocaine 23.8 56.9 36.2 P < 0.01

Other opiates 3.0 37.5 16.0 P < 0.01

Tranquilisers 6.4 35.6 17.4 P < 0.01

Any drugs (other than heroin) 69.1 92.5 77.9 P < 0.01

Any drugs 69.4 100.0 80.9 P < 0.01

Offending history

Previously incarcerated 50.6 85.6 63.8 P < 0.01

Median number adult prison terms 2.0 4.0 2.0 P < 0.01

(+SD; Range) (2.7; 1–20) (2.8; 1–15) (2.9; 1–20)

Median years in prison at baseline 1.9 1.8 1.9 NS

(+SD; Range) (4.2; 0.02-27.1) (4.1; 0.03-23.2) (4.2; 0.02-27.1)

Median sentence length in years 3.9 3.1 3.6 NS

(+SD; Range) (13.4; 0.5-113.9) (15.4; 0.4-115.8) (14.2; 0.4-115.8)

Abbreviations: SD = standard deviation; NS = not significant.

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Table 2 Smoking history, cessation behaviours and outcomes by regular use of heroin in year before prison

Not regularly used heroin %(N = 265)

Regularly used heroin %(N = 160)

Total men %(N = 425)

P-value

Smoking behaviours

Mean age first smoked tobacco 14.1 13.0 13.7 P < 0.02

(+SD; Range) (4.8; 5–39) (3.1; 5–22) (4.3; 5–39)

Mean age first smoked tobacco daily 16.0 14.6 15.5 P < 0.01

(+SD; Range) (4.6; 5–39) (3.2; 7–30) (4.2; 5–39)

Mean years smoked tobacco 20.3 19.0 19.8 NS

(+SD; Range) (11.2; 0–52) (8.4; 3–46) (10.2; 0–52)

Mean carbon monoxide reading 14.1 14.5 14.3 NS

(+SD; Range) (7.5; 1–43) (8.2; 3–59) (7.8; 1–59)

Mean cigarettes smoked per day 23.1 23.3 23.2 NS

(+SD; Range) (10.3; 3–75) (8.9; 5–60) (9.8; 3–75)

Smoke 20+ cigarettes per day 67.6 74.4 70.1 NS

High tobacco dependence (Fagerström 6+) 80.8 86.3 82.8 NS

Share a cell with a smoker 32.2 35.6 33.5 NS

Smoke White Ox (loose tobacco) 97.0 97.5 97.2 NS

Smoking cessation behaviours

Mean times tried to quit smoking 2.9 2.2 2.6 NS

(+SD; Range) (8.6; 0–128) (2.6; 0–20) (7.9; 0–128)

Quitting behaviours in past year

Given up more than one month 14.0 11.3 12.9 NS

Tried to give up unsuccessfully 64.2 53.8 60.2 P < 0.04

Lower tar or nicotine content 7.9 4.4 6.6 NS

Reduced amount tobacco smoked 50.2 43.8 47.8 NS

Quit on purpose for 24 hours 57.0 48.1 53.7 NS

Any type of quitting behaviour 76.2 68.8 73.4 NS

Smoking cessation intervention outcomes

Active NOR versus placebo NOR 49.4 46.9 48.5 NS

Quit smoking at 12 months: point prevalence 18.5 5.0 13.4 P < 0.01

Quit smoking at 12 months: continuous abstinence 16.6 3.8 11.2 P < 0.01

50% smoking reduction at 12 months 76.2 72.2 74.7 NS

Abbreviations: SD = standard deviation; NS = not significant; NOR = nortriptyline.

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investigated regular heroin use as a possible risk factor foran unsuccessful quit smoking attempt. As nearly half ofsmokers die of a tobacco-related illness [28] and the annualmortality rate for heroin-dependent people is a further 2%[29], the combined risk factors of smoking and heroindependence have important public health implications.The findings of this study suggest that future smoking

cessation interventions should consider identifying con-current drug addictions (particularly heroin) and identifystrategies to deal with all drug problems at the sametime. There is a growing body of evidence supportingmultiple behaviour change interventions which can beapplied to addressing smoking cessation and drug use[30,31]. A recent meta-analysis of the outcomes of smoking

cessation interventions among participants in drug andalcohol treatment identified that smoking cessation inter-ventions were associated with a 25% increase in long-termdrug and alcohol abstinence [32], a finding supported byother studies [33,34]. As many persons undergoing treat-ment for heroin dependence in the community may laterenter prison [35], strong support to quit smoking shouldbe provided as a routine in all drug treatments for heroindependence.Prisoners with a history of regular heroin use in the

year prior to entering prison had significantly poorer socialdeterminants of health such as poor educational attain-ment, higher involvement in out-of-home care, and werealso more likely to be homeless. These determinants are

Table 3 Predictors (crude and adjusted odds ratios) of smoking abstinence at 12 months

Point prevalence Continuous abstinence

Crude Adjusted Crude Adjusted

Odds Ratio (95% CI) Odds ratio (95% CI) Odds Ratio (95% CI) Odds ratio (95% CI)

Active NOR versus placebo NOR 0.81 (0.46-1.42) 0.89 (0.49-1.62) 0.98 (0.54-1.77) 1.07 (0.57-2.00)

Age 35+ years 1.86 (1.06-3.25)† 1.46 (0.77-2.75) 1.64 (0.91-2.97) 1.36 (0.70-2.65)

Aboriginal origin 0.50 (0.19-1.31) 0.53 (0.19-1.48) 0.60 (0.23-1.56) 0.61 (0.22-1.72)

Left school no qualification 0.55 (0.31-1.01) - 0.70 (0.38-1.29) -

Institutionalised as a child 0.66 (0.36-1.21) - 0.60 (0.32-1.16) -

Homeless prior to prison 0.70 (0.21-2.39) - 0.82 (0.24-2.82) -

Employed while in prison 1.74 (0.87-3.48) - 1.89 (0.89-4.02) -

Tried to give up unsuccessfully 0.89 (0.51-1.57) - 0.75 (0.41-1.36) -

First time in prison 2.19 (1.25-3.84)† 1.47 (0.79-2.72) 2.52 (1.38-4.57)† 1.68 (0.88-3.20)

Incarcerated 5+ years at baseline 2.67 (1.44-4.96)† 2.30 (1.17-4.52)† 2.16 (1.11-4.20)† 1.88 (0.91-3.88)

Not regular drug use (excluding heroin) in yearprior to prison

2.37 (1.33-4.19)† 1.31 (0.65-2.62) 2.39 (1.30-4.39)† 1.33 (0.64-2.75)

Not regular heroin use in year prior to prison 4.31 (1.98-9.36)† 3.81 (1.65-8.78)† 5.11 (2.13-12.29)† 4.29 (1.69-10.90)†

Abbreviations: NOR = nortriptyline † P < 0.05.

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also important risk factors for smoking tobacco, and theyreduce the success rate for smoking cessation interventions[36,37]. Further, participants who used heroin regularlyprior to prison also were significantly more likely to havebeen previously incarcerated and had a median of twice asmany previous times in prison compared to those who hadnot used heroin regularly. Increased involvement in thecriminal justice system is likely to exacerbate poverty,homelessness and other social disadvantages which are as-sociated with tobacco smoking [38].Another key characteristic of prisoners who had regu-

larly used heroin in the year before entering prison isthat they started smoking at a younger age and reportedsignificantly more other drug use than prisoners whodid not report regular heroin use. It is well documentedthat drug and alcohol treatment services often fail to ad-dress underlying tobacco dependence [39-41]. Some rea-sons for this include inadequate staff knowledge andtraining for providing smoking cessation interventions,high smoking prevalence rates among staff, and ambiva-lent attitudes and beliefs related to tobacco among staff[41]. These barriers to providing smoking cessation amongpeople with drug and alcohol problems may be addressedthrough providing enhanced staff education and training insmoking cessation, supporting staff to quit smoking andcreating a smoke-free environment for drug and alcoholtreatment services [42]. The magnitude of the barriers totreatment provision and uptake for prisoners coupled withthe major adverse biological and social factors associatedwith severe drug dependence [43], suggests that verypowerful interventions to assist smoking cessation will berequired to increase quit rates in this population.

LimitationsOne limitation of this study is that heroin use wasassessed by participant self-report, so may not reflect thetrue proportion of prisoners who had ever or recentlyused heroin. Some prisoners may have been concernedabout admitting to an illegal behaviour while in prison.However, the use of independent research nurses wasexpected to improve the confidence of participants thattheir responses would be kept confidential. This studywas also limited by only including males so cannot ne-cessarily be generalised for female prisoners. Also, thisstudy was also limited by its stringent inclusion and ex-clusion criteria, which were necessary in ensuring safeadministration of nortriptyline, but which excluded a highproportion of men interested in quitting smoking. It is notpossible to determine if the men who were eligible weremore or less likely to use heroin than those who were notso the generalisability of these findings must be consideredwith caution. Another limitation of the study is that partici-pants were not asked if they were on an opioid substitutionprogram or if they were currently using heroin so we can-not determine if this had an impact on smoking cessationsuccess. Despite these limitations, this study has a numberof strengths including: a strong follow-up rate of 80% at12 months; recruitment across nearly all male prisons inNSW; adherence to a rigorous study protocol; and utilisinga tailored multi-component smoking cessation interven-tion that was piloted among prisoners [3].

ConclusionsThe key finding of this study was that, before enteringprison, prisoners who had regularly used heroin were

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significantly less likely to have successfully quit smokingthan prisoners who did not report regular heroin use.This suggests that smoking cessation interventions forprisoners should take into account prisoners’ recent drug(particularly heroin) use in order to develop an effectiveintervention which tackles both smoking and illicit druguse. More research may assist in determining if these inter-ventions should occur as a combined model or separatelyand the optimal timing of their implementation.Many prisoners wish to quit smoking. Incarceration

presents an opportune time to attempt engaging pris-oners in smoking cessation interventions. More researchis needed to determine how best to support prisonerswho regularly used heroin to quit smoking. Some evi-dence suggests that when people are able to quit smok-ing, they are better able to stop using illicit drugs, whichmay result in reductions in re-offending, as well as sig-nificant improvements in health and well-being.

AbbreviationsSD: Standard deviation; NS: Not significant; NOR: Nortriptyline; NSW: NewSouth Wales.

Competing interestsThe authors declare that they have no competing interests.

Authors’ contributionsRR, KW, TB and AW were involved in all aspects of this study fromconceptualisation, funding, and development of questionnaire for baselineand follow-up assessments. DI and VA joined the study and made substantialcontributions to data acquisition. DI conducted the data analysis andprepared the draft manuscript. All authors have been involved in datainterpretation, finalising the manuscript, and have given final approval ofthe version to be published.

AcknowledgementsThis work was supported by the National Health and Medical ResearchCouncil (Project Grant 350829) the NSW Department of Health, Justice &Forensic Mental Health Network and the Queensland Department of Health.NRT was provided free-of-charge by GlaxoSmithKline. This trial from whichthese findings were generated is registered with the Australian New ZealandClinical Trials Registry #12606000229572.We would like to acknowledge the prison research nurses, Anne Cole andPhe Affleck, who administered the baseline questionnaires and tenaciouslyfollowed up the prisoners, and Drs Andrew Zdenkowski, Laurie Varga andKen Kuen who conducted the medical assessment of all participants for thestudy. We would also like to acknowledge Dr Alun Richards, ExecutiveDirector - Offender Health Services Directorate, Queensland Health, forintroducing the study into Borallon Correctional Centre in Queensland.Invaluable assistance was provided by the research nurses Elizabeth Baxter,Luke McCreddie, Anne Cole and Phe Affleck in NSW and Adair Behrends inQueensland, as well as the Justice Health Chief Pharmacists Hana Abdallaand Steven Crago, A/Data Co-ordinator Robyn Hetherington and MeganKent A/Services Manager. Quitline was provided to the inmates by Quitlinestaff: Bronwyn Crosby, David Lester, Leah McLeod, Jennifer Blundell, JakeDocker, Jillian MacDonald and Matthew Nelson in NSW and Kerryn Nicks inQueensland. We would also like to acknowledge Joanne Hunnisett whoentered and cleaned the considerable data bank, and Fran Hyslop who alsoworked on the ethics applications and the literature review.

Author details1Justice & Forensic Mental Health Network, Centre for Health Research inCriminal Justice, Suite 302, Level 2, 152 Bunnerong Road, Pagewood, NSW2035, Australia. 2School of Public Health and Community Medicine, Universityof New South Wales, Sydney, NSW 2052, Australia. 3Alcohol and DrugService, St Vincent’s Hospital, 390 Victoria Street, Sydney, NSW 2010, Australia.

4Kirby Institute, University of New South Wales, Sydney, NSW 2052, Australia.5Faces in the Street, Institute of Urban Mental Health and Wellbeing, StVincent’s Hospital, Level 6, O’Brien Centre, 390 Victoria Street, Sydney, NSW2010, Australia. 6School of Psychiatry, University of New South Wales, Sydney,NSW 2052, Australia.

Received: 3 July 2013 Accepted: 9 December 2013Published: 19 December 2013

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doi:10.1186/1471-2458-13-1200Cite this article as: Indig et al.: Heroin use impairs smoking cessationamong Australian prisoners. BMC Public Health 2013 13:1200.

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